The Outcome of the Elderly Living Kidney Donors in a Single Tertiary Center in Malaysia

Living-kidney transplantation increases with years, however, the rate is comparatively low to support local needs. Marginal living donors like the elderly were used to increase the donor pool. We retrospectively evaluate the outcome of 25 elderly living kidney donors (eLKDs) who were ≥60 years old at the time of donation in our center. Their medical history and laboratory results were analyzed retrospectively from e-medical records. There are 16 females (64.0%) with a median age of 63 (60.5-66.0). The mean follow-up duration was 4.36 ± 2.46 years. Their mean body mass index increased from 23.70 ± 3.07 kg/m² to 24.21 ± 2.93 kg/m² (t[14] = –2.176, P = .047) post donation. Systolic blood pressure (SBP) increased from 133.33 ± 11.65 mm Hg to 140.56 ± 17.78 mm Hg (t[17] = –2.124, P = .049). However, the prevalence of overweight and hypertension were not significant. Only 5.56% of the eLKDs developed proteinuria post nephrectomy (P =1.000). Serum creatinine increased from 62.33 ± 14.39 mmol/L to 104.63 ± 28.53 mmol/L post 1-month donation (t[23] = –9.720, P = .000) and decreased to 99.67 ± 22.39 mmol/L post 1-year donation (t[17] = –8.415, P = .006), and latest results were 94.28 ± 20.74mmol/L (t[17] = –6.630, P = .033). Fasting blood glucose and HbA1c level recorded no significant changes post donation. We noted that 47.62% of the eLKDs had dyslipidemia pre donation, which increased to 76.20% post donation (P = .031). eLKDs with hyperuricemia increased significantly from 5.88% to 52.94%; with uric acid level from 306.12 ± 68.67 umol/L to 412.24 ± 74.14 umol/L (t[16] = –7.726, P = .000). None of the eLKDs were diagnosed with metabolic syndrome pre and post kidney donation. Postdonation kidney function of the eLKDs compensated well and were stable in the short term. We noted statistically significant increments of weight, body mass index, SBP, uric acid, and lipid levels, which did not translate to clinical significance post donation. Elderly living-kidney donation can be done safely with close monitoring post donation.     

Living kidney donation does not adversely affect serum calcification propensity and markers of vascular stiffness

Living kidney donors (LKDs) experience a decline in glomerular filtration rate (GFR) after donation. Calcification propensity (T₅₀) can be determined by a blood test predicting all‐cause mortality in patients with chronic kidney disease. We studied the impact of kidney donation on T₅₀ and markers of arterial stiffness. We analyzed T₅₀ prospectively before and 1 year after kidney donation in 21 LKDs along with fetuin‐A, mineral metabolism markers, kidney length, pulse wave velocity (PWV), augmentation index (AI), and renal resistive index (RRI) as markers of arterial stiffness. We studied the impact of kidney donation on these parameters. LKDs were 54 ± 10 years old and had a GFR of 101 ± 18 ml/min/1.73 m² before donation, decreasing to 67 ± 8 ml/min/1.73 m² after donation (P < 0.001). Despite this, T₅₀ improved after donation (290 ± 53 to 312 ± 38 min, P = 0.049). This change was inversely related to plasma phosphate (P = 0.03), which declined after donation (P = 0.002). Fetuin‐A levels increased after donation (P = 0.01). Upon donation, the length of the remaining kidney increased (P < 0.001) while PWV, AI, and RRI remained unchanged. Calcification propensity was not adversely affected by kidney donation. This indicates that T₅₀ is independent from GFR in LKDs and that kidney donation does neither worsen calcification propensity nor markers of vascular stiffness at 1 year.     

The impact of religiously tailored and ethically balanced education on intention for living organ donation among Muslim Americans

We tested the efficacy of religiously tailored and ethically balanced education upon living kidney organ donation intent among Muslim Americans. Pre-post changes in participant stage of change, preparedness, and likelihood judged efficacy. Among 137 participants, mean stage of change toward donation appeared to improve (0.59; SD ± 1.07, P < .0001), as did the group's preparedness to make a donation decision (0.55; SD ± 0.86, P < .0001), and likelihood to donate a kidney (0.39; SD ± 0.85, P < .0001). Mean change in likelihood to encourage a loved one, a co-worker, or a mosque community member with ESRD to seek a living donor also increased (0.22; SD ± 0.84, P = .0035, 0.23; SD ± 0.82, P = .0021, 0.33; SD ± 0.79, P < .0001 respectively). Multivariate ordered logistic regression models revealed that gains in biomedical knowledge regarding organ donation increased odds for positive change in preparedness (OR = 1.20; 95% CI 1.01-1.41, P = .03), while increasing age associated with lower odds of positive change in stage of change (OR = 0.98, 95% CI 0.96-0.998, P = .03), and prior registration as an organ donor lowered odds for an increase in likelihood to donate a kidney (OR = 0.22; 95% CI 0.08-0.60, P = .003). Our intervention appears to enhance living kidney donation-related intent among Muslim Americans [Clinicaltrials.gov number: NCT04443114].     

The landscape of international living kidney donation in the United States

In the United States, kidney donation from international (noncitizen/nonresident) living kidney donors (LKDs) is permitted; however, given the heterogeneity of healthcare systems, concerns remain regarding the international LKD practice and recipient outcomes. We studied a US cohort of 102 315 LKD transplants from 2000‐2016, including 2088 international LKDs, as reported to the Organ Procurement and Transplantation Network. International LKDs were more tightly clustered among a small number of centers than domestic LKDs (Gini coefficient 0.76 vs 0.58, P < .001). Compared with domestic LKDs, international LKDs were more often young, male, Hispanic or Asian, and biologically related to their recipient (P < .001). Policy‐compliant donor follow‐up was substantially lower for international LKDs at 6, 12, and 24 months postnephrectomy (2015 cohort: 45%, 33%, 36% vs 76%, 71%, 70% for domestic LKDs, P < .001). Among international LKDs, Hispanic (aOR = _0.230.36_0.56, P < .001) and biologically related (aOR = _0.390.59_0.89, P < .01) donors were more compliant in donor follow‐up than white and unrelated donors. Recipients of international living donor kidney transplant (LDKT) had similar graft failure (aHR = _0.780.89_1.02, P = .1) but lower mortality (aHR = _0.530.62_0.72, P < .001) compared with the recipients of domestic LDKT after adjusting for recipient, transplant, and donor factors. International LKDs may provide an alternative opportunity for living donation. However, efforts to improve international LKD follow‐up and engagement are warranted.     

Factors associated with perceived donation‐related financial burden among living kidney donors

The perception of living kidney donation–related financial burden affects willingness to donate and the experience of donation, yet no existing tools identify donors who are at higher risk of perceived financial burden. We sought to identify characteristics that predicted higher risk of perceived financial burden. We surveyed 51 living kidney donors (LKDs) who donated from 01/2015 to 3/2016 about socioeconomic characteristics, predonation cost concerns, and perceived financial burden. We tested associations between both self‐reported and ZIP code–level characteristics and perceived burden using Fisher's exact test and bivariate modified Poisson regression. Donors who perceived donation‐related financial burden were less likely to have an income above their ZIP code median (14% vs. 72%, P = .006); however, they were more likely than donors who did not perceive burden to rent their home (57% vs. 16%, P = .03), have an income <$60 000 (86% vs. 20%, P = .002), or have had predonation cost concerns (43% vs. 7%, P = .03). Perceived financial burden was 3.6‐fold as likely among those with predonation cost concerns and 10.6‐fold as likely for those with incomes <$60 000. Collecting socioeconomic characteristics and asking about donation‐related cost concerns prior to donation might allow transplant centers to target financial support interventions toward potential donors at higher risk of perceiving donation‐related financial burden.     

Impact of Immunosuppressive Strategies on Post–Kidney Transplantation Thrombocytopenia

BackgroundThrombocytopenia after kidney transplantation is a common complication, partly induced by immunosuppressive therapies. Peritransplant thrombocytopenia may cause serious hemorrhages. We assessed the incidence of early posttransplantation thrombocytopenia (defined as a platelet count of <150,000 mm³ or <150 G/L) in de novo kidney transplant recipients (KTRs) across 4 immunosuppressive regimens.MethodsThis was a single-center observational study that included all consecutive KTRs who received either Thymoglobulin (THY) or Grafalon (GRA) and maintenance therapy of either mycophenolate-mofetil (MMF) or everolimus (EVR), associated with tacrolimus/corticosteroids.ResultsBetween July 27, 2016, and September 7, 2018, 237 KTRs were included; 64.6% experienced thrombocytopenia within the first week. Thrombocytopenia was significantly more frequent (P = .004) among GRA-treated patients (73.4%) compared to THY-treated patients (61.3%). These patients also had lower nadir platelet count (120 ± 52 vs 142 ± 48 G/L; P = .002) and lower platelet count at discharge (227 ± 94 vs 243 ± 92 G/L; P = .25). More of the GRA-EVR group had thrombocytopenia (81.0% vs 61.4% in THY-MMF, 60.9% in THY-EVR, and 69.8% in GRA-MMF; P = .081) and a worse nadir platelet count (109 ± 41 in GRA-EVR vs 141 ± 47G/L in THY-MMF, 145 ± 52 G/L in THY-EVR, and 125 ± 56 G/L in GRA-MMF; P = .011) but GRA was the only risk factor for thrombocytopenia in multivariate analyses (P = .002). Rates of hemorrhage, red blood cell transfusions, reoperations needed within the first week, delayed graft function, acute rejection, graft loss, and death did not differ between the groups after a mean follow-up of 25 ± 8 months.ConclusionsGRA associated with EVR led to more frequent and severe thrombocytopenia, although we found no significant clinical consequences.     

Comparison of Clinical Outcomes Among Deceased Donor Kidney Transplant Recipients Before and After Utilizing Estimated Posttransplant Survival Score for Kidneys Allocation in Malaysia

Background. The Malaysian Kidney Allocation System implemented in 2020 includes only kidney transplant candidates with estimated posttransplant survival (EPTS) score of ≤20%, in replacement of Malaysian Organs Sharing System, which was based solely on dialysis vintage. We aim to compare the clinical outcomes of deceased-donor kidney transplant recipients (DDKTRs) with EPTS ≤20% to those with EPTS >20%.Methods. All DDKTRs between January 1, 2015, and December 29, 2020, were included and categorized into 2 groups: EPTS ≤20% and EPTS >20%. Cox regression was performed to evaluate the association of EPTS score and patient survival. The rate of postoperative complications, graft failure and patient survival were compared between 2 groups. Data were analyzed with SPSS v26 and R v4.0.4. The study complies with the Helsinki Congress and the Istanbul Declaration.Results. We included 159 DDKTRs, with a median follow-up of 25 months (range, 10-60 months). The mean age of those with EPTS ≤20% was 32.2 ± 3.4 years and those with EPTS >20% was 46.0 ± 6.7 years, and the median EPTS score were 16% (range, 12%-18%) and 38% (range, 27%-56.5%), respectively. EPTS score was associated with patient survival (hazard ratio, 1.031; 95% CI 1.010-1.052; P = .003), and the cutoff points of 30% and above were associated with worse survival. It showed good discrimination (C-index, 0.729; 95% CI 0.579-0.878; P = .003) and the optimal cutoff value was 38% (65.5% sensitivity, 68.8% specificity, 17.8% positive predictive value, and 95.8% negative predictive value). Both groups had similar rate of surgical complications (P = .191), graft failure (P = .503), and patient survival (P = .654), but those with EPTS >20% had higher incidence of urinary tract infection (9.3% vs 27.6%, P = .016).Conclusions. There was no difference in clinical outcomes using an EPTS cutoff point of 20% but worse patient survival if higher cutoff point was used.     

Proximal aortic repair in dialysis patients: A national database analysis

ObjectivesDialysis is a well-established risk factor for morbidity and mortality after cardiovascular procedures. However, little is known regarding the outcomes of proximal aortic surgery in this high-risk cohort.MethodsPerioperative (in-hospital or 30-day mortality) and 10-year outcomes were analyzed for all the patients who underwent open proximal aortic repair with the diagnosis of nonruptured thoracic aortic aneurysm (aneurysm, n = 325) or type A aortic dissection (dissection, n = 461) from 1987 to 2015 using the US Renal Data System database.ResultsIn patients with aneurysm, perioperative mortality was 12.6%. The 10-year mortality was 81% ± 3%. Age 65 years or more (hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.03 to 1.78; P = .03), chronic obstructive pulmonary disease (HR, 1.68; 95% CI, 1.01-2.82; P = .047), and Black race (HR, 1.46; 95% CI, 1.09-1.97; P = .01) were independently associated with worse 10-year mortality. In patients with dissection, perioperative mortality was 24.3% and 10-year mortality was 87.9% ± 2.2%. Age 65 years or more (HR, 1.49; 95% CI, 1.19-1.86; P < .001), congestive heart failure (HR, 1.39; 95% CI, 1.11-2.57; P = .004), and diabetes mellitus as the cause of dialysis (HR, 1.75; 95% CI, 1.2-2.57; P = .004) were independently associated with worse 10-year mortality. Black race (HR, 0.74; 95% CI, 0.6-0.92; P = .008) was associated with a better outcome.ConclusionsWe described challenging perioperative and 10-year outcomes for dialysis patients undergoing proximal aortic repair. The present study suggests the need for careful patient selection in the elective repair of proximal aortic aneurysm for dialysis-dependent patients, whereas it affirms the feasibility of emergency surgery for acute type A aortic dissections.     

Patterns and predictors of fatigue following living donor nephrectomy: Findings from the KDOC Study

This study sought to identify the prevalence, pattern, and predictors of clinical fatigue in 193 living kidney donors (LKDs) and 20 healthy controls (HCs) assessed at predonation and 1, 6, 12, and 24 months postdonation. Relative to HCs, LKDs had significantly higher fatigue severity (P = .01), interference (P = .03), frequency (P = .002), and intensity (P = .01), and lower vitality (P < .001), at 1‐month postdonation. Using published criteria, significantly more LKDs experienced clinical fatigue at 1 month postdonation, compared to HCs, on both the Fatigue Symptom Inventory (60% vs. 37%, P < .001) and SF‐36 Vitality scale (67% vs. 16%, P < .001). No differences in fatigue scores or clinical prevalence were observed at other time points. Nearly half (47%) reported persistent clinical fatigue from 1 to 6 months postdonation. Multivariable analyses demonstrated that LKDs presenting for evaluation with a history of affective disorder and low vitality, those with clinical mood disturbance and anxiety about future kidney failure after donation, and those with less physical activity engagement were at highest risk for persistent clinical fatigue 6 months postdonation. Findings confirm inclusion of fatigue risk in existing OPTN informed consent requirements, have important clinical implications in the care of LKDs, and underscore the need for further scientific examination in this population.     

Insulin Sensitivity After Living Donor Nephrectomy

BackgroundThe kidney is essential for glucose and insulin metabolism. Living kidney donors (LKDs) experience a reduction in glomerular filtration rate of 25 to 30 mL/min after donor nephrectomy. Little is known about the effect of glomerular filtration rate decline on insulin sensitivity in LKDs.MethodsWe conducted a prospective pilot study on 9 LKDs (N = 9) who underwent dynamic metabolic testing (mixed meal tolerance test) to measure proxies of insulin sensitivity (homeostatic model assessment of insulin resistance, the area under curve [AUC] for insulin/glucose ratio, and Matsuda insulin sensitivity index) before and 3 months after donor nephrectomy. The primary outcome was the change in insulin sensitivity indices (delta [post-nephrectomy – pre-nephrectomy]).ResultsFour of the donors had a body mass index (BMI) between 32.0 and 36.7 predonation. Post–donor nephrectomy, compared with prenephrectomy values, median insulin AUC increased from 60.7 to 101.7 hr*mU/mL (delta median 33.3, P = .04) without significant change in median glucose AUC levels from 228.9 to 209.3 hr*mg/dL (delta median 3.2, P = .77). There was an increase in the median homeostatic model assessment of insulin resistance from 2 to 2.9 (delta median 0.8, P = .03) and the AUC insulin/glucose ratio from 30.9 to 62.1 pmol/mmol (delta median 17.5, P = .001), whereas the median Matsuda insulin sensitivity index decreased from 5.9 to 2.9 (delta median −2, P = .05). The changes were more pronounced in obese (BMI >32) donors.ConclusionLKDs appear to have a trend toward a decline in insulin sensitivity post–donor nephrectomy in the short term, especially in obese donors (BMI >32). Further investigation with a larger sample size and longer follow-up is needed.     

Clinical Impact of Subclinical Interstitial Fibrosis or Tubular Atrophy in 1-Hour Allograft Biopsy for Remnant Renal Function in Living Kidney Donors: A Prospective Observational Study

BackgroundPreservation of remnant renal function (RRF) is one of the major concerns among living kidney donors (LKDs). A comprehensive assessment is needed to predict the RRF. In this prospective study, we investigated the roles of histologic findings from a 1-hour allograft biopsy in predicting the RRF.MethodsOur prospective study included 116 LKDs who underwent donor nephrectomy (DN) at our institute. Clinical and radiographic data were obtained from their medical charts. Renal volume parameters were calculated using the preoperative computed tomographic images in the volume analyzer SYNAPSE VINCENT image analysis system. Tissues obtained from allograft biopsy were examined. RRF was defined as the estimated glomerular filtration rate (eGFR) 12 months after DN.ResultsOf 116 LKDs, 95 were finally evaluated. The median age of the LKDs at DN and the preoperative eGFR were 57 years and 80.0 mL/min/1.73 m², respectively. In the histologic analysis, 68 allografts (71.6%) had nonspecific findings involving the glomerulus, vessel, and tubulointerstitium. Interstitial fibrosis or tubular atrophy (IF/TA) was the only significant predictive factor for RRF (P = .039). No significant association was found between renal volume parameters and IF/TA, whereas remnant renal volume adjusted by body weight (RRV/BW) tended to be relatively correlated with IF/TA (P = .072). Furthermore, LKDs with subclinical IF/TA tended to have decreased RRV/BW compared with those without subclinical IF/TA (P = .088).ConclusionsOur findings suggested that the presence of IF/TA could be a predictive factor for RRF after DN. Further research establishing the predictive model for RRF is warranted to improve the outcomes of LKDs.     

Hand-Assisted Retroperitoneoscopic Donor Nephrectomy Compared to Anterior Approach Open Donor Nephrectomy: Improved Long-Term Physical Component Score in Health-Related Quality of Life in Living Kidney Donors

BackgroundHealth-related quality of life (HRQL), fatigue, anxiety, and depression are crucial for the living kidney donor (LKD). Follow-up data for HRQL of LKDs comparing surgical techniques, especially regarding hand-assisted retroperitoneoscopic donor nephrectomy (HARP), are sparse. The aim of this study was to evaluate the influence of abdominal wall trauma minimized by HARP in comparison to open anterior approach donor nephrectomy (AA) on HRQL and additional psychosocial aspects of LKDs during the long-term follow-up.Material and MethodsThis is a cross-sectional study comparing psychosocial aspects of LKD between HARP and AA.ResultsThis study included 100 LKDs (68 HARP, 28 AA, and 4 were excluded secondary to incomplete data). The time to follow-up was 22.6 ± 11.7 (HARP) vs 58.7 ± 13.9 (AA) months (P < .005). Complications ≥3a° due to Clavien-Dindo classification was 0% in both groups. There were higher scores in all physical aspects for HARP donors vs AA donors at that time (physical function: 89.8 ± 14.6 vs 80.0 ± 19.9, P = .008, and the physical component score: 53.9 ± 7.6 vs 48.6 ± 8.5, P = .006). One year later (follow-up time + 12 months), HRQL for HARP donors was still higher. Mental items showed no significant differences. HARP donors showed better physical scores compared to the age-matched nondonor population (AA donors had lower scores). Neither the Multidimensional Fatigue Inventory-20 (MFI-20) or the Hospital Anxiety and Depression Scale (HADS) showed any differences between the 2 groups. Fatigue scores were higher for HARP and for AA compared to the age-matched population.ConclusionsLKDs undergoing HARP showed better physical performance as part of HRQL in the long-term follow-up.     

Multimodal analgesia after thyroid or parathyroid surgery: A randomized controlled trial

BackgroundThe opioid epidemic prompted reevaluation of surgeons’ opioid prescribing practices. This study aimed to demonstrate noninferiority of a staged analgesic regimen after endocrine surgery.MethodsWe conducted a randomized controlled trial comparing analgesic regimens after thyroidectomy and/or parathyroidectomy. Adult patients (≥18 years) were randomized to study arm (A) as-needed acetaminophen + codeine or (B) scheduled acetaminophen/as-needed tramadol. Patients recorded pain scores and analgesics consumed in a study log. Clinical variables were collected from the medical record.ResultsTarget enrollment was achieved (n = 126), and randomization was even (A: 44.5%, B: 55.6%). There was no difference between enrolled patients and those who returned the study log (52.4%) by sex (P = .667), age (P = .513), final pathology (P = .137), procedure (P = .667), or randomization arm (P = .795). Most patients (50.8%) reported moderate pain scores (4–6) with no difference between study arms (P = .451). There was no difference in average consumption by morphine milligram equivalents (A: 11.5 ± 12.1 vs B: 12.49 ± 18.07; P = .792) nor total analgesic doses (A: 7.29 ± 7.48 vs B: 8.5 ± 5.36; P = .445). However, a significant difference in average percentage of opioid doses was noted (A: 79.71 ± 33.31 vs B: 27.38 ± 31.88; P < .001).ConclusionPatients reported moderate pain scores with low requirements for analgesics after endocrine surgery. The staged analgesic regimen is noninferior to combination opioids and led to reduced overall consumption.     

ETPOD (European Training Program on Organ Donation): a successful training program to improve organ donation

Advanced training of healthcare professionals active in organ donation is highlighted as a major means to overcome organ shortage. The objective of this study was to improve donation rates in the selected European target areas (TAs) by providing an advanced training program. A prospective intervention study was conducted in 25 TAs with active donor programs from 17 European countries, between 2007 and 2009. A training program based on collaborative methodology was designed at three different professional levels (health workers awareness, junior transplant coordinators, managers). Courses evaluation scores and donation figures in each TA were collected and compared before and after intervention. Courses with new developed training tools were implemented reaching out 3286 healthcare professionals. Feed‐back questionnaires revealed a high degree of satisfaction among participants (average of 4.35 on a 1–5 scale). The number of utilized donors in the TAs increased from 15.7 ± 14.3 (95% CI: 9.8–21.6) to 20.0 ± 17.1 (95% CI: 13–27.1) (P = 0.014) and the number of organs recovered increased from 49.7 ± 48.5 (95% CI: 29.6–69.7) to 59.3 ± 52.1 (95% CI: 37.8–80.8) (P = 0.044). The European Training Program on Organ Donation is a successful training program, achieving a significant increase in organ donation figures.     

A Higher Glomerular Filtration Rate Predicts Low Risk of Developing Chronic Kidney Disease in Living Kidney Donors

Background

The risk of developing chronic kidney disease (CKD) among living kidney donors (LKDs) is seldom included in evaluations of patients’ outcomes. Potential risk factors and new criteria for estimating the glomerular filtration rate (eGFR) indexed for body surface area (BSA) were investigated with a view to prevent the development of CKD in LKDs.

Methods

We conducted a retrospective study of LKDs from May 1983 to March 2011. The Mann–Whitney U test and χ² test were used to analyze the male versus female groups. Survival analysis was plotted as CKD-free survival and analyzed separately by different eGFR index classifications. The Cox regression model was used to identify potential risk factors for development of CKD.

Results

A total of 105 LKDs with a mean age of 46.3 ± 12.5 years had a mean eGFR indexed for BSA of 88.9 ± 21.5 ml/min per 1.73 m². After a mean duration of 5.4 ± 4.9 years’ follow-up, eGFR dropped to 61.4 ± 16.4 ml/min per 1.73 m² (p = 0.002). Median CKD-free survival was only 5.7 years. The difference between eGFR ≥ 80 ml/min per 1.73 m² and <80 ml/min per 1.73 m² was not statistically significant (p = 0.980). Multivariate Cox regression analysis showed that higher eGFR at donation (HR = 0.952, p = 0.0199) could be a protective factor. The receiver operating characteristic (ROC) curve for initial eGFR with best sensitivity of 52.78 % and specificity of 81.40 % was obtained with a cutoff value of 90.2 ml/min per 1.73 m² for preoperative eGFR. An eGFR of 90 ml/min per 1.73 m² yielded a significant survival curve (p = 0.0199) after 21 years of follow-up. Further classifications of eGFR >90 ml/min per 1.73 m² into 90–99 ml/min per 1.73 m², 100–109 ml/min per 1.73 m², and ≥110 ml/min per 1.73 m² were examined, but this survival curve was not statistically significant (p = 0.1247).

Conclusions

Living kidney donors will develop CKD after a long duration of follow-up if there is insufficiently high eGFR at donation. An eGFR above 90 ml/min per 1.73 m² before donation is the only factor that predicts prevention of CKD. Larger studies with longer duration of follow-up are necessary to clarify the clinical outcome of this postoperative CKD group, especially for patients with eGFR between 80 and 90 ml/min per 1.73 m².     

In vivo demonstration of Pseudomonas aeruginosa biofilms as independent pharmacological microcompartments

BackgroundPseudomonas aeruginosa is difficult to eradicate from the lungs of cystic fibrosis (CF) patients due to biofilm formation. Organs and blood are independent pharmacokinetic (PK) compartments. Previously, we showed in vitro biofilms behave as independent compartments impacting the pharmacodynamics. The present study investigated this phenomenon in vivo.MethodsSeaweed alginate beads with P. aeruginosa resembling biofilms, either freshly produced (D0) or incubated for 5 days (D5) were installed s.c in BALB/c mice. Mice (n = 64) received tobramycin 40 mg/kg s.c. and were sacrificed at 0.5, 3, 6, 8, 16 or 24 h after treatment. Untreated controls (n = 14) were sacrificed, correspondingly. Tobramycin concentrations were determined in serum, muscle tissue, lung tissue and beads. Quantitative bacteriology was determined.ResultsThe tobramycin peak concentrations in serum was 58.3 (±9.2) mg/L, in lungs 7.1 mg/L (±2.3), muscle tissue 2.8 mg/L (±0.5) all after 0.5 h and in D0 beads 19.8 mg/L (±3.5) and in D5 beads 24.8 mg/L (±4.1) (both 3 h). A 1-log killing of P. aeruginosa in beads was obtained at 8h, after which the bacterial level remained stable at 16 h and even increased in D0 beads at 24 h. Using the established diffusion retardation model the free tobramycin concentration inside the beads showed a delayed buildup of 3 h but remained lower than the MIC throughout the 24 h.ConclusionsThe present in vivo study based on tobramycin exposure supports that biofilms behave as independent pharmacological microcompartments. The study indicates, reducing the biofilm matrix would increase free tobramycin concentrations and improve therapeutic effects.     

Nurse Intervention: Attitudes and Knowledge About Organ Donation and Transplantation in Adolescents

BackgroundThe problems involved in obtaining authorization in favor of organ donation have led us to evaluate the level of knowledge and attitudes of a group of Spanish adolescents (14-16 years) regarding organ donation, transplantation, and brain death. The evaluation was carried out before and after a health education intervention by nursing personnel.MethodsExperimental, prospective and quantitative study. The educational intervention was carried out at Las Salinas high school (Laguna de Duero, Spain). We collected 86 preworkshop questionnaires and 88 post-workshop questionnaires.ResultsThe composition of the groups did not differ significantly in sex (P = .653), age (P = .266), or in the desire to be a donor (P = .099). We found significant postworkshop improvements in knowledge about brain death (P < .001) and which organs can be donated (P < .001), as well as in the total score (18.29 ± 2.45 before vs 21.47 ± 2.70 after) (P < .001). We discovered a vast lack of knowledge about the organs that cannot be transplanted, which included the penis (38.4%), uterus (31.4%), prostate (41.9%), or bladder (37.2%); these beliefs decreased significantly after the intervention (P < .01). The increase in knowledge of the organs that can be donated, including eye (P = .024), lung (P = .025), stomach (P < .001), intestine (P = .001), and skin (P < .001), was also significant.ConclusionsThe good results reflected the importance of conducting educational programs taught by health personnel on donation and organ transplantation in adolescents.     

Posttransplant muscle mass measured by urinary creatinine excretion rate predicts long‐term outcomes after liver transplantation

Long‐term survival in orthotopic liver transplant (OLT) recipients remains impaired because of many contributing factors, including a low pretransplant muscle mass (or sarcopenia). However, influence of posttransplant muscle mass on survival is currently unknown. We hypothesized that posttransplant urinary creatinine excretion rate (CER), an established noninvasive marker of total body muscle mass, is associated with long‐term survival after OLT. In a single‐center cohort study of 382 adult OLT recipients, mean ± standard deviation CER at 1 year posttransplantation was 13.3 ± 3.7 mmol/24 h in men and 9.4 ± 2.6 mmol/24 h in women. During median follow‐up for 9.8 y (interquartile range 6.4‐15.0 y), 104 (27.2%) OLT recipients died and 44 (11.5%) developed graft failure. In Cox regression analyses, as continuous variable, low CER was associated with increased risk for mortality (HR = 0.43, 95% CI: 0.26‐0.71, P = .001) and graft failure (HR = 0.42, 95% CI: 0.20‐0.90, P = .03), independent of age, sex, and body surface area. Similarly, OLT recipients in the lowest tertile had an increased risk for mortality (HR = 2.69; 95% CI: 1.47‐4.91, P = .001) and graft failure (HR = 2.77, 95% CI: 1.04‐7.39, P = .04), compared to OLT recipients in the highest tertile. We conclude that 1 year posttransplant low total body muscle mass is associated with long‐term risk of mortality and graft failure in OLT recipients.